Hopkins Restorative Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by the resident assessments, plans of care, and facility assessment. This had the potential to affect all residents residing in the facility. Bowel and Bladder - See F690 - R3 Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], reported she had intact cognition, had no hallucinations, delusions, rejections of care, and no verbal, physical or other behavioral symptoms towards herself or others. The MDS identified R3 was dependent on staff for toileting hygiene and transfers, required substantial to maximal assist for mobility and all other transfers, had no urinary catheters, had not trialed a urinary or bowel toileting training program and was frequently incontinent of urine and bowel. Additionally, the MDS identified R3 was at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility failed to complete annual performance reviews for 5 of 5 nursing assistants (NA-B, NA-C, NA-D, NA-H, NA-M) whose employee files were reviewed. This had the potential to affect all 37 residents who resided at the facility. Findings include: A review of employee records on 12/12/24 between 1:24 p.m., and 2:37 p.m., lacked documentation of completed annual performance reviews. All 5 sampled employees were employed at the facility for greater than one year. Per interview on 12/12/24 at 2:11 p.m., the administrator stated it was their understanding the previous director of nursing (DON) completed competencies with annual reviews. The administrator stated, I'm looking through file cabinets and if I can't find them, I can't say that we have them without them. Per interview on 12/16/24 at 12:01 p.m., the DON had no luck locating the annual performance reviews or recent completed competencies for the sampled NA's. The DON stated the facility would be restarting those reviews beginning January 1st and indicated it was important because…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure staff performed appropriate hand hygiene during medication administration for 2 of 3 residents (R2, R6) observed during medication administration, and failed to implement enhanced barrier precautions (EBP) for 6 of 7 residents (R4, R9, R14, R18, R26, R29) reviewed for precautions. Further, the facility failed to develop and implement a Legionella risk assessment and plan to mitigate the growth of Legionella. This had the potential to affect all 37 residents, staff and visitors. Findings include: Hand Hygiene R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact with diagnoses of coronary artery disease (arteries which supply blood to the heart become narrowed or blocked), heart failure, hypertension, and diabetes mellitus. R6's quarterly MDS dated [DATE], indicated R6 was cognitively intact with diagnoses of hypertension, urinary tract infection, diabetes mellitus, dementia, anxiety, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and document review, the facility failed to ensure structural issues and items in disrepair throughout the facility were addressed to help promote a functional, sanitary, and safe environment. Additionally, the facility failed to ensure an ice and water dispensing machine in the second floor TCU and LTC (transitional care unit and long-term care) dining room was clean and free of excess mineral build up and properly functioning. This had the potential to affect all 37 residents residing in, visitors, and staff working in the facility. Findings include: A resident council meeting was held on 12/10/24 at 10:00 a.m., and residents in attendance reported the condition of the facility was a shithole. The residents stated they were aware there was no maintenance in the building to fix the multiple problems in resident rooms, dining rooms, hallways, and the holes in the walls. MAIN KITCHEN During observation on 12/11/24 at 11:37 a.m., the wall across from the main kitchen refrigerator had multiple blackish-brownish colored speckles. The area under the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure consultant pharmacist recommendations were acted upon timely for 4 of 5 residents (R1, R5, R8, R14) reviewed for unnecessary medications. Findings include: R1 R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, inattention and disorganized thinking which fluctuated, did not have physical, verbal, or other behavioral symptoms, did not reject cares, had diagnoses of heart failure, hypertension (high blood pressure), thyroid disorder, arthritis (conditions which cause inflammation of the joints), osteoarthritis (chronic disease when cartilage which lines joints are worn down and bones rub against each other), and adjustment disorder with mixed anxiety and depressed mood. Further, R1 took an antipsychotic and antidepressant. R1's Order Summary Report dated 12/12/24, indicated the following orders: - 11/27/24, Depakote oral tablet delayed release 500 mg (used for manic depression). Give one tablet by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility failed to ensure required in-service training based on annual performance reviews was completed for 5 of 5 nursing assistants (NA-B, NA-C, NA-D, NA-H, NA-H) whose employee files were reviewed. This had the potential to affect all 37 residents who resided at the facility. Findings include: A review of employee records on 12/12/24 between 1:24 p.m. and 2:37 p.m., lacked documentation of completed annual performance reviews. Furthermore, the employee records lacked documentation of in-service training that addressed areas of weakness determined by performance reviews. All 5 sampled employees were employed at the facility for greater than one year. Per interview on 12/12/24 at 2:11 p.m. with the administrator, it was believed the previous director of nursing (DON) completed competencies with annual reviews. The administrator stated, I'm looking through file cabinets and if I can't find them, I can't say that we have them without them. Per interview on 12/16/24 at 12:01 p.m., the DON had no luck locating the performance reviews,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure resident-specific resuscitation wishes were clear and evident throughout the electronic medical record (EMR) and physical paper chart for 1 of 1 resident (R22) reviewed for advance directives. Findings include: R22's admission Minimum Data Set (MDS) dated [DATE], indicated R22 had short- and long-term memory problems, severely impaired cognitive skills for daily decision making, and continuous inattention and disorganized thinking. R22's diagnoses included hypertension, renal failure, hip fracture, osteoporosis, depression, Alzheimer's disease, and dementia. During record review on [DATE] at 6:00 p.m., R22 did not have an order for code status. R22's banner in the EMR had a link to Advance Directives which was blank and did not have a POLST (a medical order indicating treatments a person would like to receive in case of serious illness and/or cardiac arrest) uploaded in the EMR. Progress notes and care conference summaries indicated R22's code…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to notify providers about a resident's weight status while on a prescribed diuretic (water pill) for 1 of 1 residents reviewed for edema (swelling). Findings include: R5's significant change Minimum Data Set (MDS) dated [DATE], indicated she had severe cognitive impairment with diagnoses of heart failure, kidney failure, respiratory failure, anxiety, depression, and lymphedema (a chronic condition causing swelling from lymph or protein-rich fluid in the body's tissues). The MDS further indicated R5 received hospice care. R5's Care Area Assessment (CAA) for functional abilities dated 11/5/24, identified her need for assistance with all activities of daily living (ADLs) and mobility, directing staff to provide max assist with all cares and dependent assistance with toileting and transfer cares. The CAA directed staff to proceed to the plan of care with goal of comfort and dignity with end of life cares. R5's unsigned order summary was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provided Notice of Medicare Non-Coverage (NOMNC) in the required time frame for 1 of 3 residents (R143) reviewed for beneficiary notices. Findings include: R143 admission minimum data set (MDS) dated [DATE], included R143 had moderate cognitive impairment and diagnosis of dementia. Facility progress note dated 10/7/24, included R143's power of attorney (POA) discussed a discharge for resident on 10/9/24. R143's NOMNC dated 10/9/24, included skilled nursing/therapy services will end 10/8/24. Handwritten note on document read resident elects early discharge with benefit days remaining. NOMNC was signed by resident. No evidence of POA reviewing or signing document. During interview on 12/12/24 at 11:17 a.m., family member (FM)-B stated she did not remember ever being informed about a notice of Medicare non-coverage, but was updated that therapy would be ending. During interview on 12/13/24 at 10:45 a.m., registered nurse (RN)-D confirmed the discharge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and documentation review, the facility failed to ensure a safe, clean, comfortable homelike environment when the facility failed to address maintenance issues identified in the dining areas, resident rooms, and throughout the building for 2 of 8 residents (R30, R36) reviewed for homelike environment. Findings include: R30's admission record printed 12/16/24, indicated he admitted to the facility on [DATE]. A complaint/incident investigation reported by R30 and dated 9/16/24, was reviewed and indicated the facility itself is very unsanitary. The report included, one part of the walls at the facility is currently missing, and staff did not appear to be doing anything to fix this. A complaint/incident investigation reported by R30 and dated 10/8/24, was reviewed and indicated the facility had environmental issues but lacked specificity on where the alleged mold was. A complaint/incident investigation reported by R30 and dated 11/27/24, was reviewed and identified a fire hazard and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) was completed to screen for mental health needs for 1 of 1 residents (R8) reviewed for PASARR. Findings include: R8 admission Minimum Data Set (MDS) dated [DATE], included diagnosis of schizophrenia. R8's order summary report dated 4/3/24, included diagnoses of mild cognitive impairment, schizoaffective disorder (a mental health disorder with symptoms of both schizophrenia and a mood disorder), depression, bipolar disorder (extreme mood swings), and hoarding disorder. R8's preadmission screening results (PAS) dated 1/11/24, included the R8 would need a Level II assessment for mental illness. During interview on 12/11/24 at 9:11 a.m., social services (SS)-A stated she did an audit of all PAS results when she was hired and R8's previous PAS was unclear, but she thought she may have needed a Level II. SS-A resubmitted R8's PAS information at that time. SS-A stated she did not realize…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a shower was offered or provided for 1 of 3 residents (R30) reviewed for bathing. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], indicated he had moderately impaired cognition with a memory deficit following a cerebrovascular accident (CVA, or a stroke), weakness and paralysis or inability to move his left dominant side after a stroke, depression, and dementia (a condition causing a decline in cognitive function, memory, and behavior). His MDS indicated he displayed no rejection of cares and required substantial to maximal staff assistance for bathing/showering cares and mobility and transfers. R30's annual MDS dated [DATE], identified bathing preferences were very important to him. R30's functional abilities Care Area Assessment (CAA) dated 6/24/24, was triggered due to his need for assistance with ADL cares and identified he was at risk for ADL decline and directed staff to the plan of care. R30's care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a resident's preferred activities for individual entertainment were offered for 1 of 1 residents (R26) reviewed for activities. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had severely impaired cognition and was marked not applicable for transfers. The MDS identified diagnoses of muscle weakness, depression, and high blood pressure. R26's significant change MDS dated [DATE], indicated it was very important to R5 to participate in her favorite activities and to go outside and get fresh air when the weather is good. R26's Care Area Assessment (CAA) for communication dated 1/3/24, indicated R5 was usually understood and usually understands. The CAA identified she was at risk for missed information and unmet needs as her primary language was Russian, but she did know some English. The CAA indicated she was able to make her needs known and guided staff to proceed the plan of care. An activity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a resident was comprehensively assessed for appropriate treatment and services to prevent urinary tract infections (UTIs) and to restore continence to the extent possible for 1 of 1 residents (R3) reviewed for toileting programs. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], reported she had intact cognition, no hallucinations, delusions, or verbal, physical or other behavioral symptoms towards herself or others. The MDS identified R3 was dependent on staff for toileting hygiene and transfers, required substantial to maximal assist for mobility and all other transfers, had no urinary catheters, had not trialed a urinary or bowel toileting training program and was frequently incontinent of urine and bowel. Additionally, the MDS identified R3 was at risk for pressure injury wound. R3's Care Area Assessment (CAA) for urinary incontinence dated 11/8/24, confirmed the risk for skin breakdown and stated, she is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure prescription topical medications were applied and documented in accordance with professional standards of practice for 1 of 2 residents (R26) observed during morning activities of daily living (ADL) cares. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition and substantial to moderate staff assistance with personal and toileting hygiene cares. The MDS identified diagnoses of muscle weakness, depression, and high blood pressure. R26's undated and unsigned order summary was reviewed 12/11/24, and reflected the following active physician orders: - Nystatin external powder 100000 unit/gm (gram) (Nystatin (Topical)) Apply to skin folds topically as needed for rash under breasts, dated 9/9/24. - Nystatin powder (Nystatin (Bulk)) Apply to groin topically every 12 hours as needed for groin, dated 10/8/24 A request for R26's most recently signed order summary was requested but not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide appropriate side effect monitoring (including vital and orthostatic blood pressure monitoring) and obtain informed consent for psychotropic medication and ensure a PRN (as needed) psychotropic medication order included an end date for 1 of 5 resident (R1) reviewed for unnecessary medication use. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, inattention and disorganized thinking which fluctuated, did not have physical, verbal, or other behavioral symptoms, did not reject cares, had diagnoses of heart failure, hypertension (high blood pressure), thyroid disorder, arthritis (conditions which cause inflammation of the joints), osteoarthritis (chronic disease when cartilage which lines joints are worn down and bones rub against each other), and adjustment disorder with mixed anxiety and depressed mood. Further R1 took an antipsychotic and antidepressant. R1's Order Summary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a bed remote control was monitored and kept in safe condition for 1 of 1 resident (R16) reviewed for bed controls. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE], indicated R16 had severely impaired cognition and diagnoses of heart failure, diabetes mellitus, depression, and dementia. R16 had no impairment to upper and lower extremity and was independent with mobility, such as rolling left and right, sit to lying, and lying to sitting on side of bed and required more assistance with transfers and dressing. During observation and interview on 12/9/24 at 2:42 p.m., R16 laid in bed with the bed controller within reach. The bed controller cord had a black covering which had a half inch or less gap between the controller with the buttons and insulated wires were visible and not frayed. R16 stated they used their bed controller independently. When interviewed on 12/13/24 at 2:12 p.m., nursing assistant (NA)-G…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure an allegation of physical staff to resident abuse was reported timely, within two hours, as required to the State Agency (SA) and to the administrator for 1 of 1 residents (R1) reviewed for abuse. Findings include: R1's significant change Minimal Data Set (MDS) dated [DATE], indicated R1's diagnoses included dementia and personality disorder. R1's cognition was not impaired. Review of facility report number 358043 submitted to the SA on 9/24/24 at 5:41 p.m., identified R1 had reported a nursing assistant (NA) while providing cares was angry and telling R1 not to use the call light and it made her angry. R1 reported NA pinched her in the left leg and grabbed her hair with water on her hands. R1 was able to identify the staff as NA-A. On 10/2/24 at 10:32 a.m., licensed practical nurse (LPN)-A stated staff were expected to report allegations of abuse to the nurse manager, director of nursing (DON) and administrator immediately. On 10/2/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to immediately implement an intervention to protect 1 of 1 residents (R1) following an allegation of physical staff to resident abuse. This deficient practice had the potential to affect all other residents currently residing in the facility. Findings include: R1's significant changes Minimal Data Set (MDS) dated [DATE], indicated R1's diagnoses included dementia and personality disorder. R1's cognition was not impaired. Review of facility report number 358043 submitted to the SA on 9/24/24 at 5:41 p.m. R1 had reported a nursing assistant (NA) while providing cares was angry and telling R1 not to use the call light and it made her angry. R1 reported NA pinched her in the left leg and grabbed her hair with water on her hands. R1 was able to identify the staff as NA-A. Review of NA-A's timecard dated 10/2/24, indicated NA-A had clocked in for work at 5:31 a.m. and clocked out at 3:34 p.m., on the day of the alleged incident 9/24/24. On 10/2/24 at 10:41…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and document review, the facility failed to ensure proper sanitization of dishware used for meal preparation and resident service when 1 of 1 high-temperature commercial dishwashers was identified as not reaching adequate wash and rinse temperatures. This had potential to affect all 43 residents within the facility, staff, and visitors who consumed food from the main production kitchen. Findings include: During interview and observation on 2/28/24 at 9:51 a.m., kitchen manager (KM) stated the facility dishwasher used chemical sanitization and required a water temperature of 150 degrees Fahrenheit (°F) during the wash cycle and 180°F during the final rinse, and temperature readings were recorded after the last load of dishes after each meal. KM stated one staff person usually loaded the trays with dishes, placed them on the conveyor of the auto-feed dish machine and KM usually removed them when they were done. KM requested another staff person to demonstrate the machine by starting to wash the dirty breakfast dishes. During the first load at 9:55…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review the facility failed to ensure the Quality Assessment and Assurance (QAA)/ and Quality Assurance process improvement (QAPI) committee was effective in implementing approrpiate action plans to correct a quality deficiency identified during a previous survey related to Influenza and Pneumococcal vaccinations which resulted in a deficiency identified during this survey. This deficient practice had the potential to affect all 43 residents curretnly residing in the facility. Findings include: Review of the CASPER report dated 2/15/24, indicated the facility was cited F883 for Influenza and Pneumococcal vaccinations on the surveys which exited on 12/21/22 and will be cited on this survey exited on 3/1/24. See F883: Based on interview and record review, the facility failed to accurately assess residents' eligibility to receive the pneumococcal vaccination according to The Centers of Disease and Control and Prevention (CDC) for 2 of 5 (R 35, R28) residents reviewed for vaccinations. Furthermore, the facility failed to ensure the influenza vaccination…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to perform monthly preventative maintenance inspections of resident transfer equipment prior to R4's fall during mechanical lift use. This had the potential to impact 14 residents requiring the use of a mechanical lift. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and R4 was totally dependent on staff assistance for transfers. MDS also indicated diagnoses of right-sided weakness and immobility due to a stroke, dementia (loss of memory, language, problem-solving and other thinking abilities), depression, and anxiety. R4's Care Area Assessment (CAA) for falls dated 6/19/23, indicated R4 was at risk due to his immobility. The CAA indicated R4 required the use of a Hoyer mechanical lift for transfers. R4's CAA for activities of daily living (ADL) functional and rehabilitation potential dated 6/19/23, also indicated R4's dependence on staff assistance and use of a hoyer for transfers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure urinary catheter drainage bags were covered to maintain dignity for 1 of 1 residents (R32) reviewed for dignity. Findings include: R32's annual Minimum Data Set (MDS) dated [DATE], indicated she was rarely understood and had diagnoses of alcohol-induced dementia (loss of memory, language, problem-solving and other thinking abilities) and obstructive uropathy (disorder of the urinary tract caused by urinary flow obstruction). Furthermore, R32's MDS indicated she had an indwelling urinary catheter. R32's Care Area Assessment (CAA) for urinary incontinence and indwelling catheter was triggered and indicated R32 required staff assistance with toileting and had an indwelling catheter in place due to her obstructive uropathy. The CAA indicated staff would assist with catheter cares and provide interventions per R32's plan of care. R32's care plan dated 10/25/22, indicated her catheter bag should be in a dignity bag attached to her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a self-administration of medication assessment was completed to allow a resident to safely administer their own medication for 1 of 1 residents (R11) observed self-administrating a nebulizer treatment. Findings include: R11's quarterly Minimum Data Set, dated [DATE], indicated R11 had intact cognition and diagnoses of hypertension, respiratory failure, chronic obstructive pulmonary disease (COPD; lung disease which blocks airflow and makes it difficult to breathe), and malnutrition. R11 had impairments to both upper and lower extremities, was independent with bed mobility and eating, and required partial/moderate and/or dependent assistance with activities of daily living (ADLs) such as dressing and personal hygiene. R11's MDS indicated they received hospice services. R11's annual MDS dated [DATE] did not indicate R11 had impairment to upper or lower extremities. R11's care plan dated 3/1/24, indicated an alteration in respiratory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure R33 had access to the bathroom in their room. In addition, the facility failed to ensure R4 had access to their call light for two of two residents (R4 and R33) reviewed for reasonable accomodation of needs and preferences. Findings include: R33's quarterly Minimum Data Set, dated [DATE], identified R33 was cognitively intact, had diagnoses of stroke with left sided weakness and dementia, required set-up for oral care, substantial assistance with toilet transfers, was independent with using their wheelchair for short distances, and incontinent of bowel and bladder. R33's quarterly Bladder/Bowel assessment dated [DATE], indicated he was incontinent of bladder and continent of bowel. R33's care plan dated 12/29/23, included R33 required assist of one staff for toileting due to left sided weakness and directed staff to offer to stand pivot transfer to toilet before breakfast, after lunch, and at bedtime. R33's Kardex (nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R12) had a vision appointment for decreased vision. Findings include: R12's annual Minimum Data Set (MDS) dated [DATE], indicated R12 had short-term and long-term memory problems and moderately impaired daily decision-making cognitive skills. The MDS did not indicate rejection of cares. The MDS indicated R12 had schizophrenia, hypertension, and moderately impaired vision. R12's Care Area assessment dated [DATE], indicated R12 had diagnosis of myopia (condition in which close objects appear clearly, but far ones don't), did not wear glasses, and was at risk for further loss of vision and falls. During record review on 2/29/24, R12's careplan lacked interventions for vision impairment. R12's admission Record dated 3/1/24, indicated R12 had partial retinal artery occlusion of the right eye and retinal artery branch occlusion of the left eye with onset date of 10/6/21. On 2/26/24 at 5:13 p.m., R12 laid in their bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure provider orders for pressure relieving devices were in place for 1 of 5 residents (R23) reviewed for pressure injury. Furthermore, the facility failed to ensure assessment and monitoring for pressure injury was provided for 1 of 5 (R144) residents reviewed for pressure injury. Finding include: R23's significant change Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of Alzheimer's disease, type II diabetes and did not have a history of refusing care. It further indicated R23 required moderate assistance with rolling side to side and was dependent on staff for mobility and toileting. R23 was at risk for and had one facility acquired stage III pressure ulcer on her left heel. R23's physician's order dated 9/11/23 indicated to use blue heel protector boots when in bed every evening and night shift for wound prevention. R23's care plan dated 2/21/24, lacked any mention of blue foam boots/heel protectors.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure appropriate management of an indwelling catheter was provided for 1 of 2 residents (R35) reviewed for indwelling catheter. Findings include: R35's significant change Minimum Data Set (MDS) dated [DATE], indicated R12 had an indwelling catheter, did not have a trial of a toileting program, and always incontinent of bowel. The MDS indicated R35 was cognitively intact and diagnosis of cirrhosis (condition in which liver is scarred and permanently damaged), manic depression, and post-traumatic stress disorder. R35's Care Area Assessment (CAA) dated 1/29/24, indicated R35 was dependent on staff for toileting hygiene and at risk for urinary tract infections and other complications related to catheter use. R35's indwelling urinary catheter care plan dated 11/13/23, directed staff to change urinary collection bag as needed, provide catheter care, educate resident /representative on catheter care, evaluate as needed for possible removal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and document review, the facility failed to ensure medications were labeled with current, accurate physician orders to reduce the risk of administration error for 1 of 5 residents (R33) observed to receive medication during the survey. Findings include: R33's Order Summary Report dated 3/1/24, identified an order which read Famotidine Oral Tablet 20 MG (Famotidine) Give 20 mg by mouth two times a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE WITH ESOPHAGITIS, WITHOUT BLEEDING with start date of 6/8/23. Another order read tizanidine HCI Oral Tablet 4 MG (Tizanidine HCI) Give 4 mg by mouth two times a day for Spastic left hemiparesis with start date of 2/22/24. On 2/28/24 at 7:40 a.m., licensed practical nurse (LPN-C) prepared medications for R33 in the hallway from a mobile cart. LPN-C presented the Famotidine 20 milligram (mg) medication card, and the directions on the label of the medication card directed, GIVE 1 TABLET VIA TUBE TWICE DAILY. The start date on the label was 2/9/24. There were no other directions or guidance displayed on the label…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure current standards of practice for glove us and handwashing were being followed for 1 of 3 residents (R35) when staff provided personal care. Findings include: R35's significant change Minimum Data Set (MDS) dated [DATE], indicated R35 was cognitively intact, had an indwelling catheter, and always incontinent of bowel. The MDS indicated R35 was dependent on staff for toileting hygiene and required partial/moderate assistance to roll left to right. During observation on 2/29/24 at 10:05 a.m., nursing assistant (NA)-A and NA-C assisted R35 with catheter and peri-cares. NA-C wiped bowel movement from R35's bottom and removed soiled brief. NA-C removed gloves, did not perform hand hygiene, and placed new gloves on. NA-C assisted R35 with clean incontinent product and placed barrier cream on R35's bottom. NA-C removed gloves, did not perform hand hygiene, and placed on new gloves. NA-C assisted R35 to reposition in bed and gave R35 the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess residents' eligibility to receive the pneumococcal vaccination according to The Centers of Disease and Control and Prevention (CDC) for 2 of 5 (R 35, R28) residents reviewed for vaccinations. Furthermore, the facility failed to ensure the influenza vaccination was offered 1 of 5 residents (R35) reviewed for vaccinations. Findings include: The Center for Disease Control and Prevention identified on the Pneumococcal Vaccine Timing for Adults Chart, dated 3/15/23, Adult [AGE] years of age or older who had received the PPSV23 (pneumococcal polysaccharide vaccine 23) only at any age should receive one dose of either pneumococcal 20-valent Conjugate Vaccine (PCV20) or pneumococcal 15-valent Conjugate Vaccine (PCV15). The dose of PCV20 or PCV15 should be administered at least one year after the most recent PPSV23 dose. R35's admission Minimum Data Set (MDS) dated [DATE], indicated R35 was cognitively intact and had diagnoses of alcohol…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to assess 2 of 3 residents (R1, R2) reviewed for self-administration of medications. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had moderately impaired cognition. R1's admission assessment dated [DATE] indicated R1 did not wish to self-administer medications. R1's Provider Orders dated 6/6/23 included metoprolol tartrate (medication to treat high blood pressure and pulse) 12.5 milligrams (mg) two times a day and apixaban (medication to prevent blockage of blood vessels) 5 mg 2 times a day. Both medications to be administered at 8 a.m. and 8 p.m. R1's electronic medical record (EMR) lacked an assessment and provider order for self-administration of medications. R2's quarterly MDS dated [DATE] indicated intact cognition. R2's admission assessment dated [DATE] indicated R2 did not wish to self-administer medications. R2's Provider Orders dated 3/9/23 included metoprolol tartrate 25 mg 2 times a day to be administered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.